Minimizing hemodynamic compromise during post-mi remodeling control pacing

ABSTRACT

A method and device for delivering pre-excitation pacing to prevent or reduce cardiac remodeling following a myocardial infarction is described. The pre-excitation pacing is modulated in accordance with an assessment of cardiac function in order to balance the beneficial effects of stress reduction with hemodynamic compromise.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of U.S. Provisional Application No.60/678,337, filed on May 6, 2005, under 35 U.S.C. § 119(e), which ishereby incorporated by reference.

FIELD OF THE INVENTION

This patent application pertains to methods and apparatus for thetreatment of cardiac disease. In particular, it relates to methods andapparatus for improving cardiac function with electro-stimulatorytherapy.

BACKGROUND

A myocardial infarction is the irreversible damage done to a segment ofheart muscle by ischemia, where the myocardium is deprived of adequateoxygen and metabolite removal due to an interruption in blood supply. Itis usually due to a sudden thrombotic occlusion of a coronary artery,commonly called a heart attack. If the coronary artery becomescompletely occluded and there is poor collateral blood flow to theaffected area, a transmural or full-wall thickness infarct can result inwhich much of the contractile function of the area is lost. Over aperiod of one to two months, the necrotic tissue heals, leaving a scar.The most extreme example of this is a ventricular aneurysm where all ofthe muscle fibers in the area are destroyed and replaced by fibrous scartissue.

Even if the ventricular dysfunction as a result of the infarct is notimmediately life-threatening, a common sequela of a transmuralmyocardial infarction in the left ventricle is heart failure broughtabout by ventricular remodeling. Left ventricular remodeling is aphysiological process in response to the hemodynamic effects of theinfarct that causes changes in the shape and size of the left ventricle.Remodeling is initiated in response to a redistribution of cardiacstress and strain caused by the impairment of contractile function inthe infarcted area as well as in nearby and/or interspersed viablemyocardial tissue with lessened contractility due to the infarct. Theremodeling process following a transmural infarction starts with anacute phase which lasts only for a few hours. The infarcted area at thisstage includes tissue undergoing ischemic necrosis and is surrounded bynormal myocardium. Over the next few days and months after scar tissuehas formed, global remodeling and chamber enlargement occur in a thirdphase due to complex alterations in the architecture of the leftventricle involving both infarcted and non-infarcted areas. Remodelingis thought to be the result of a complex interplay of hemodynamic,neural, and hormonal factors.

It has been shown that the extent of ventricular remodeling ispositively correlated with increased mortality in post-MI patients. Itis with reversing and/or preventing such ventricular remodeling that thepresent invention is primarily concerned.

SUMMARY

The part of the myocardium that is most vulnerable to the post-infarctremodeling process is the infarct region, which is an area that includessites in and around the infarct where the myocardial fibers are stillintact but contractile function is impaired. The infarct region is thusthe area most likely to undergo progressive dilation described abovewith wall thinning and further impairment of function. By pacingmyocardial sites in proximity to the infarct with appropriately timedpacing pulses, the infarct region is pre-excited in a manner thatlessens the mechanical stress to which it is subjected, thus reducingthe stimulus for remodeling. Pre-excitation of one or more myocardialsites, however, may have an adverse effect on cardiac function bycausing less efficient pumping. Described herein is a device and methodwhich provides pre-excitation of myocardial sites to control remodelingin a manner which minimizes hemodynamic compromise.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates the physical placement of an implantable cardiacdevice.

FIG. 2 is a system diagram of a cardiac device configured for multi-sitestimulation and sensing.

FIG. 3 illustrates an exemplary algorithm for modulating pre-excitationpacing.

DETAILED DESCRIPTION

The degree to which a heart muscle fiber is stretched before itcontracts is termed the preload, while the degree of tension or stresson a heart muscle fiber as it contracts is termed the afterload. Themaximum tension and velocity of shortening of a muscle fiber increaseswith increasing preload, and the increase in contractile response of theheart with increasing preload is known as the Frank-Starling principle.When a myocardial region contracts late relative to other regions, thecontraction of those other regions stretches the later contractingregion and increases its preloading, thus causing an increase in thecontractile force generated by the region. Conversely, a myocardialregion that contracts earlier relative to other regions experiencesdecreased preloading and generates less contractile force. Becausepressure within the ventricles rises rapidly from a diastolic to asystolic value as blood is pumped out into the aorta and pulmonaryarteries, the parts of the ventricles that contract earlier duringsystole do so against a lower afterload than do parts of the ventriclescontracting later. Thus, if a ventricular region can be made to contractearlier than parts of the ventricle, it will be subjected to both adecreased preload and afterload which decreases the mechanical stressexperienced by the region relative to other regions during systoliccontraction. The region will also do less work thus lessening itsmetabolic demands and the degree of any ischemia that may be present.

If the region around an infarct were made to contract during earlysystole, it would be subjected to less distending forces and less likelyto undergo expansion, especially during the period immediately after amyocardial infarction. In order to cause early contraction and lessenedstress, electro-stimulatory pacing pulses may be delivered to one ormore sites in or around the infarct in a manner that pre-excites thosesites relative to the rest of the ventricle. (As the term is usedherein, a pacing pulse is any electrical stimulation of the heart ofsufficient energy to initiate a propagating depolarization, whether ornot intended to enforce a particular heart rate.) In a normal heartbeat,the specialized His-Purkinje conduction network of the heart rapidlyconducts excitatory impulses from the sino-atrial node to theatrio-ventricular node, and thence to the ventricular myocardium toresult in a coordinated contraction of both ventricles. Artificialpacing with an electrode fixed into an area of the myocardium does nottake advantage of the heart's normal specialized conduction system forconducting excitation throughout the ventricles because the specializedconduction system can only be entered by impulses emanating from theatrio-ventricular node. Thus the spread of excitation from a ventricularpacing site must proceed only via the much slower conducting ventricularmuscle fibers, resulting in the part of the ventricular myocardiumstimulated by the pacing electrode contracting well before parts of theventricle located more distally to the electrode. This pre-excitation ofa paced site relative to other sites can be used to deliberately changethe distribution of wall stress experienced by the ventricle during thecardiac pumping cycle in order to prevent or reduce the remodeling thatwould otherwise occur. Pre-excitation of the infarct region relative toother regions unloads the infarct region from mechanical stress bydecreasing its afterload and preload, thus preventing or minimizing theremodeling that would otherwise occur. Pacing therapy to unload theinfarct region may be implemented by pacing the ventricles at a singlesite in proximity to the infarct region or by pacing at multipleventricular sites in such proximity. In the latter case, the pacingpulses may be delivered to the multiple sites simultaneously or in adefined pulse output sequence. As described below, the single-site ormultiple site pacing may be performed in accordance with a bradycardiapacing algorithm such as an inhibited demand mode or a triggered mode.

Pre-excitation of a particular myocardial site or sites in order tolessen the mechanical stress to which they are subjected during systolemay also, however, have the unfortunate effect of compromising cardiacfunction. This can come about because pre-excitation of a ventricularregion causes that region to contract earlier than other regions,resulting in an asynchronous contraction of the ventricle. Such anasynchronous contraction is less efficient than in the normal situationwhere all regions of the ventricle contract almost simultaneously.Post-MI patients with already weakened hearts may not tolerate thisasynchrony well and exhibit lessened systolic pressure and/or strokevolume. Described herein is a device and method which providespre-excitation of myocardial sites to control remodeling and which alsomonitors cardiac function in order to modulate the pre-excitation pacingin a manner which minimizes hemodynamic compromise.

1. Exemplary Device Description

As shown in FIG. 1, an implantable cardiac device 100 for delivering CRTis typically placed subcutaneously or submuscularly in a patient's chestwith leads 200 threaded intravenously into the heart to connect thedevice to electrodes 300 used for sensing and pacing of the atria and/orventricles. Electrodes may also be positioned on the epicardium byvarious means. A programmable electronic controller causes the pacingpulses to be output in response to lapsed time intervals and sensedelectrical activity (i.e., intrinsic heart beats not as a result of apacing pulse). The device senses intrinsic cardiac electrical activitythrough a sensing channel which incorporates internal electrodesdisposed near the chamber to be sensed. A depolarization wave associatedwith an intrinsic contraction of the atria or ventricles that isdetected by the device is referred to as an atrial sense or ventricularsense, respectively. In order to cause such a contraction in the absenceof an intrinsic beat, a pacing pulse with energy above a certainthreshold is delivered to the chamber through a pacing channel whichincorporates internal electrodes disposed near the chamber to be paced.

A block diagram of an exemplary pacemaker for delivering pre-excitationpacing therapy to a site or sites in proximity to an infarct asdescribed above is illustrated in FIG. 2. Pacemakers are usuallyimplanted subcutaneously in the patient's chest and connected tosensing/pacing electrodes by leads either threaded through the vesselsof the upper venous system to the heart or by leads that penetrate thechest wall. (As the term is used herein, a “pacemaker” should be takento mean any cardiac rhythm management device with a pacing functionalityregardless of any other functions it may perform.) The controller of thepacemaker is made up of a microprocessor 10 communicating with a memory12 via a bidirectional data bus, where the memory 12 typically comprisesa ROM (read-only memory) for program storage and a RAM (random-accessmemory) for data storage. The controller could be implemented by othertypes of logic circuitry (e.g., discrete components or programmablelogic arrays) using a state machine type of design, but amicroprocessor-based system is preferable. The controller is capable ofoperating the pacemaker in a number of programmed modes where aprogrammed mode defines how pacing pulses are output in response tosensed events and expiration of time intervals. A telemetry unit 80 isalso provided for communicating with an external programmer.

The device illustrated in FIG. 2 has multiple sensing and pacingchannels and is therefore capable of delivering single-site or multiplesite ventricular pacing. The multiple sensing and pacing channels may beconfigured as either atrial or ventricular channels allowing the deviceto deliver such pacing with or without atrial tracking. Shown in FIG. 2is a configuration with one atrial sensing/pacing channel and threeventricular sensing/pacing channels. The atrial sensing/pacing channelcomprises ring electrode 53 a, tip electrode 53 b, sense amplifier 51,pulse generator 52, and an atrial channel interface 50 whichcommunicates bidirectionally with a port of microprocessor 10. The threeventricular sensing/pacing channels that include ring electrodes 23 a,33 a, and 43 a, tip electrodes 23 b, 33 b, and 43 b, sense amplifiers21, 31, and 41, pulse generators 22, 32, and 42, and ventricular channelinterfaces 20, 30, and 40. A pacing channel is made up of the pulsegenerator connected to the electrode while a sensing channel is made upof the sense amplifier connected to the electrode. The channelinterfaces include analog-to-digital converters for digitizing sensingsignal inputs from the sensing amplifiers, registers that can be writtento for adjusting the gain and threshold values of the sensingamplifiers, and registers for controlling the output of pacing pulsesand/or changing the pacing pulse amplitude. In certain patients, pacingof sites in proximity to an infarct or within ischemic regions may beless excitable than normal and require an increased pacing energy inorder to achieve capture (i.e., initiating of a propagating actionpotential). For each channel, the same electrode pair can be used forboth sensing and pacing. In this embodiment, bipolar leads that includetwo electrodes are used for outputting a pacing pulse and/or sensingintrinsic activity. Other embodiments may employ a single electrode forsensing and pacing in each channel, known as a unipolar lead. A MOSswitching network 70 controlled by the microprocessor is used to switchthe electrodes from the input of a sense amplifier to the output of apulse generator as well as configure sensing or pacing channels with theavailable electrodes.

The controller controls the overall operation of the device inaccordance with programmed instructions stored in memory. The controllerinterprets electrogram signals from the sensing channels and controlsthe delivery of paces in accordance with a pacing mode. The sensingcircuitry of the pacemaker generates atrial and ventricular electrogramsignals from the voltages sensed by the electrodes of a particularchannel. When an electrogram signal in an atrial or sensing channelexceeds a specified threshold, the controller detects an atrial orventricular sense, respectively, which pacing algorithms may employ totrigger or inhibit pacing.

Pre-excitation therapy is most conveniently delivered in conjunctionwith a bradycardia pacing mode. Bradycardia pacing modes refer to pacingalgorithms used to pace the atria and/or ventricles in a manner thatenforces a certain minimum heart rate. For example, a ventricular escapeinterval for pacing the ventricles can be defined between ventricularevents, referred to as the cardiac cycle (CC) interval with its inversebeing the lower rate limit or LRL. The CC interval is restarted witheach ventricular sense or pace. In atrial tracking and AV sequentialpacing modes, another ventricular escape interval is defined betweenatrial and ventricular events, referred to as the AV delay (AVD)interval, where a ventricular pacing pulse is delivered upon expirationof the AV delay interval if no ventricular sense occurs before. In anatrial tracking mode, the atrio-ventricular pacing delay interval istriggered by an atrial sense and stopped by a ventricular sense or pace.An atrial escape interval can also be defined for pacing the atriaeither alone or in addition to pacing the ventricles. In an AVsequential pacing mode, the atrio-ventricular delay interval istriggered by an atrial pace and stopped by a ventricular sense or pace.Atrial tracking and AV sequential pacing are commonly combined so thatan AVD interval starts with either an atrial pace or sense.

In the case where the pre-excitation pacing of the ventricle isdelivered at multiple sites, the sites may be paced simultaneously or inaccordance with a particular pulse output sequence that specifies theorder in which the sites are to be paced during a single beat.Pre-excitation pacing may involve biventricular pacing with the paces toright and left ventricles delivered either simultaneously orsequentially, with the interval between the paces termed thebiventricular offset (BVO) interval (also sometimes referred to as theLV offset (LVO) interval or VV delay). The offset interval may be zeroin order to pace both ventricles simultaneously or non-zero in order topace the left and right ventricles sequentially. As the term is usedherein, a negative BVO refers to pacing the left ventricle before theright, while a positive BVO refers to pacing the right ventricle first.As the term is used herein for biventricular pacing, the AVD intervalrefers to the interval between an atrial event (i.e., a pace or sense inone of the atria, usually the right atrium) and the first ventricularpace which pre-excites one of the ventricles, and the pacing instant forthe non-pre-excited ventricle is specified by the BVO interval so thatit is paced at an interval AVD+BVO after the atrial event. With eitherbiventricular or left ventricle-only pacing, the AVD interval may be thesame or different depending upon whether it is initiated by an atrialsense or pace (i.e., in atrial tracking and AV sequential pacing modes,respectively). A common way of implementing biventricular pacing or leftventricle-only pacing is to base the timing upon only right ventricularactivity so that ventricular escape intervals are reset or stopped byright ventricular senses.

2. Assessment of Cardiac Function

In order to minimize or lessen hemodynamic compromise resulting frompre-excitation pacing, the delivery of such pacing may be modulated inaccordance with an assessment of cardiac function. One or moreadditional sensing modalities may be incorporated into the implantabledevice for this purpose, where the additional sensors are interfaced tothe microprocessor 10. Cardiac output may be measured by an impedancetechnique in which transthoracic impedance is measured and used tocompute stroke volume. An impedance sensor 330 includes an exciter andan impedance measuring circuit. Processing of the impedance signalallows the derivation of a signal representing respiratory activityand/or cardiac blood volume, depending upon the location the voltagesense electrodes in the thorax. (See, e.g., U.S. Pat. Nos. 5,190,035 and6,161,042, assigned to the assignee of the present invention and herebyincorporated by reference.) If the electrodes are located so as tomeasure impedance across the lungs, the patient's minute ventilation maybe derived from the respiratory activity signal and may be used as anindication of exertion level. If the electrodes are located to measureimpedance across the heart, the impedance signal is filtered to removethe respiratory component, the result is a signal that is representativeof blood volume in the heart at any point in time, thus allowing thecomputation of stroke volume and, when combined with heart rate,computation of cardiac output. The stroke volume integrated over time(or averaged and multiplied by heart rate) gives the patient's cardiacoutput. The impedance technique for measuring cardiac output discussedabove may also be used to measure ventricular volumes at various stagesof the cardiac cycle such as end-diastolic and end-systolic volumes andused to compute parameters reflective of cardiac function such asejection fraction. The implantable device may also be equipped withother sensing modalities such as a pressure transducer 332. Such apressure transducer may be attached to an intravascular lead and beappropriately disposed for measuring diastolic filling pressures and/orsystolic pulse pressures.

Any or all of the parameters related to cardiac function described abovemay be used to derive a cardiac function assessment, where theassessment may simply be a cardiac function parameter (e.g., cardiacoutput) or a function of one or more such parameters. One such functionincorporates one or more cardiac function parameters along with ameasurement of the patient's exertion level. For example, cardiacfunction may be assessed by measuring both cardiac output and thepatient's exertion level. Exertion level may be measured with animpedance sensor configured to measure minute ventilation as describedabove, with an accelerometer 331 for measuring physical activity level,or heart rate if the patient is chronotropically competent. A look-uptable or other function may be used to compute what cardiac output isconsidered adequate for a given exertion level, referred to as cardiacoutput demand. The cardiac function assessment may then take the form ofa numerical value that reflects both cardiac output and the patient'sexertion level (e.g., the difference or ratio between the measuredcardiac output and cardiac demand). The value of the cardiac functionassessment in this case then varies in accordance with the adequacy ofthe patient's cardiac output as determined by the measured exertionlevel. As discussed below, the cardiac function assessment may then becompared with specified threshold values with the delivery ofpre-excitation pacing modulated in accordance with the result.Alternatively, a ratio of the extent of pre-excitation pacing to thecardiac function assessment may be computed from numerical valuesrelated to pre-excitation pacing and the cardiac function assessment,respectively. The delivery of pre-excitation pacing may then bemodulated in a manner that maintains the ratio within a specified range.

3. Exemplary Implementation

In an exemplary embodiment, an implantable device for delivering cardiactherapy to post-MI patients includes one or more pacing channels fordelivering pacing pulses to one or more ventricular sites. Thecontroller is programmed to deliver pacing which pre-excites a region ofthe ventricular myocardium so as to mechanically unload that regionduring systole. The therapy may be delivered as single-site pacing,biventricular pacing where one of the ventricles is pre-excited relativeto the other as determined by a programmed biventricular offsetinterval, or delivered as multi-site ventricular pacing where at leastone of the ventricles is paced at a plurality of sites so as topre-excite one or more of the sites relative to the other sites. In anycase, the ventricular pacing may be delivered in a non-atrial trackingmode where a ventricular escape interval is defined between ventricularpaces, or in an atrial tracking mode where the ventricular paces aredelivered after a defined atrio-ventricular escape interval following anatrial sense. In a patient who is chronotropically incompetent, anatrial pacing channel may also be provided for pacing the atria, withthe ventricular pace(s) delivered upon expiration of theatrio-ventricular escape interval following the atrial pace.

In pre-excitation pacing using an atrial tracking mode, the parameterthat determines the amount of pre-excitation is the AV delay or AVD.Delivering electrical pacing therapy near an infarct region can reducewall stress in that region to the extent that the region contractsbefore other regions contract due to intrinsic activation, and that theeffect is dependent on AV delay. As paced AV delay shortens, the size ofthe region that is unloaded is increased, and the absolute amount ofunloading in the region (as measured by a decrease in regional strokework) is increased. However, as AV delay shortens, cardiac function isreduced. Therefore, the amount of unloading produced by pre-excitationpacing and cardiac function are inversely related. In order to provide abalance between the amount of unloading and the compromise of cardiacfunction, the device is programmed to provide a closed-loop system forensuring that cardiac function is not overly compromised. FIG. 3illustrates an exemplary algorithm which may be performed by amicroprocessor and/or other circuitry as steps S1 through S5, executedserially or concurrently. The device is programmed to deliverpre-excitation pacing with a specified AVD at step S1 while monitoringcardiac function using one or more of the techniques described above atstep S2. If cardiac function falls below a specified threshold asdetermined at step S3, the device increases the AVD at step S4. Thedevice may also decrease the AVD at step S5 if cardiac function exceedsa specified threshold. Either instead of, or in addition to changing theAVD in response to a cardiac function assessment, the device couldautomatically adjust the BVO or other offset to result in more or lesspre-excitation, change the pacing site or sites, or cease or initiatepre-excitation pacing therapy.

In another embodiment, the device is programmed to calculate a specificratio between the extent of unloading and cardiac function. The deliveryof pre-excitation pacing is then made to vary in a manner that attemptsto maintain within a specified range the ratio of a parameter related tothe amount pre-excitation pacing (i.e., the amount of regional unloadingas derived from pre-excitation parameters such as AVD and BVO) to aparameter related to the cardiac function assessment. By maintaining theratio within a specified range, the device matches cardiac output topatient metabolic need as estimated by exertion level. As the patientexercises, and cardiac output demand increases, the device increase AVdelay (or adjusts other pre-excitation parameters) to reduce unloadingand maximize cardiac output. When exertion is reduced, the deviceshortens the AV delay (or adjusts other pre-excitation parameters) torestore more regional unloading for a given cardiac output level. Eitherin addition or instead of using pre-excitation parameters to reflect theextent of unloading, the extent of unloading brought about by thepre-excitation pacing could be measured by an ultrasonic transducerconnected to an intravascular lead for measuring wall thickness or by animpedance technique for determining mechanical activation time, or alocal strain gauge connected to a cardiac lead (or implanted separately)for measuring regional stress.

Although the invention has been described in conjunction with theforegoing specific embodiments, many alternatives, variations, andmodifications will be apparent to those of ordinary skill in the art.Such alternatives, variations, and modifications are intended to fallwithin the scope of the following appended claims.

1. An implantable device for delivering cardiac therapy to a patient,comprising: one or more pacing channels for delivering pacing pulses toone or more ventricular sites; a sensor for measuring a parameterrelated to cardiac function; a controller for controlling the deliveryof pacing pulses to one or more ventricular sites during a cardiac cyclein accordance with a programmed pacing mode; wherein the controller isprogrammed to deliver pre-excitation pacing which pre-excites a regionof the ventricular myocardium so as to mechanically unload that regionduring systole; and, wherein the controller is further programmed toderive a cardiac function assessment from the measured cardiac functionparameter and modulate the amount of pre-excitation pacing in accordancetherewith.
 2. The device of claim 1 wherein the controller is programmedto maintain within a specified range a ratio of cardiac function topre-excitation pacing.
 3. The device of claim 1 wherein the controlleris programmed to reduce the amount of pre-excitation pacing if thecardiac function assessment is below a specified threshold value.
 4. Thedevice of claim 1 wherein the controller is programmed to increase theamount of pre-excitation pacing if the cardiac function assessment isabove a specified threshold value.
 5. The device of claim 1 wherein thecontroller is programmed to modulate the amount of pre-excitation pacingby adjusting the AV delay of an atrial tracking mode.
 6. The device ofclaim 1 wherein the controller is programmed to modulate the amount ofpre-excitation pacing by changing the biventricular offset of abiventricular pacing mode.
 7. The device of claim 1 wherein thecontroller is programmed to modulate the amount of pre-excitation pacingby changing a pacing site.
 8. The device of claim 1 wherein thecontroller is programmed to modulate the amount of pre-excitation pacingby initiating or ceasing pre-excitation pacing.
 9. The device of claim 1wherein the sensor for measuring a parameter related to cardiac functionis an impedance sensor for measuring stroke volume.
 10. The device ofclaim 1 wherein the sensor for measuring a parameter related to cardiacfunction measures cardiac output and wherein the controller isprogrammed to derive the cardiac function assessment from the measuredcardiac output and a measured exertion level.
 11. A method fordelivering cardiac therapy to a patient, comprising: delivering pacingpulses to one or more ventricular sites as pre-excitation pacing whichpre-excites a region of the ventricular myocardium so as to mechanicallyunload that region during systole; measuring a parameter related tocardiac function; and, deriving a cardiac function assessment from themeasured cardiac function parameter and modulate the amount ofpre-excitation pacing in accordance therewith.
 12. The method of claim11 further comprising maintaining within a specified range a ratio ofcardiac function to pre-excitation pacing.
 13. The method of claim 11further comprising reducing the amount of pre-excitation pacing if thecardiac function assessment is below a specified threshold value. 14.The method of claim 11 further comprising increasing the amount ofpre-excitation pacing if the cardiac function assessment is above aspecified threshold value.
 15. The method of claim 11 further comprisingmodulating the amount of pre-excitation pacing by adjusting the AV delayof an atrial tracking mode.
 16. The method of claim 11 furthercomprising modulating the amount of pre-excitation pacing by changingthe biventricular offset of a biventricular pacing mode.
 17. The methodof claim 11 wherein further comprising modulating the amount ofpre-excitation pacing by changing a pacing site.
 18. The method of claim11 further comprising modulating the amount of pre-excitation pacing byinitiating or ceasing pre-excitation pacing.
 19. The method of claim 11further comprising measuring a parameter related to cardiac functionwith an impedance sensor for measuring stroke volume.
 20. The method ofclaim 11 further comprising measuring a parameter related to cardiacfunction by measuring cardiac output and deriving the cardiac functionassessment from the measured cardiac output and a measured exertionlevel.